Provider Demographics
NPI:1578673422
Name:ROLL, ELIZABETH J (PHD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:J
Last Name:ROLL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1616 SAN PATRICIO AVE SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87104-1048
Mailing Address - Country:US
Mailing Address - Phone:505-266-2631
Mailing Address - Fax:505-242-4763
Practice Address - Street 1:201 TULANE DR SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-1413
Practice Address - Country:US
Practice Address - Phone:505-266-2631
Practice Address - Fax:505-242-4763
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM276103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM850302029OtherEIN/TAX ID